Tumescent anesthesia: evolution and current uses.

The tumescent technique of local anesthesia is one of the great techniques developed in the last 20 years. It has dramatically changed the way clinicians perform many cutaneous surgical procedures. Those that use the technique are forever grateful for the insight that Dr. Jeffrey Klein used to push the envelope and discover the safe doses of subcutaneous administration of lidocaine.

Onion extract gel versus petrolatum emollient on new surgical scars: prospective double-blinded study.

BACKGROUND: Cutaneous scars resulting from surgical procedures can be erythematous, hypertrophic, pruritic, painful, or cosmetically unacceptable. An onion extract-based topical gel (Mederma, Merz Pharmaceuticals, Greensboro, NC, USA) has been marketed as a product to improve scar appearance and texture. However, few data are available to substantiate these claims. OBJECTIVE: To compare the efficacy between the onion extract gel and a petrolatum-based emollient (Aquaphor, Beiersdorf, Inc., Wilton, CT, USA) in improving the appearance and symptoms of new surgical scars. METHODS: Twenty-four patients with new surgical wounds of at least 4 cm in length were enrolled in the study. Using a randomized, double-blinded, split-scar study design, each scar was divided into two equal portions, and each half was assigned treatment with either onion extract gel or petrolatum ointment at the time of suture removal. Each product was applied three times daily for 8 weeks, and patients were evaluated at 2, 8, and 12 weeks following initiation of treatment. A follow-up telephone interview was conducted at least 11 months postoperatively. RESULTS: Scar halves were evaluated by blinded investigators for overall cosmetic appearance, erythema, and hypertrophy. Patients also independently rated side-specific erythema, pruritus, burning, and pain. Using the paired t-test and the Wilcoxon signed rank test, we found no statistically significant difference (p < .1) between the two treatment groups in any of the outcome variables studied. CONCLUSION: Petrolatum-based topical agents constitute standard therapy in the management of postoperative wounds. In this side-by-side, randomized, double-blinded, split-scar study, the onion extract gel did not improve scar cosmesis or symptomatology when compared with a petrolatum-based ointment.

Predictors of extensive subclinical spread in nonmelanoma skin cancer treated with Mohs micrographic surgery.

BACKGROUND: In nonmelanoma skin cancer, the clinically visible portion may represent a small fraction of microscopic tumor spread. Previous studies have examined individual risk factors for subclinical spread based on patient and tumor characteristics. However, these risk factors have not been prioritized or studied in combination. OBJECTIVE: To identify the most predictive risk factors for extensive subclinical tumor spread. DESIGN: Retrospective analysis of 1131 Mohs micrographic surgical cases. Variables analyzed included patient age, sex, and immune status and lesion size, location, histologic subtype, and recurrence. Logistic regression was applied to identify important combinations of tumor characteristics and to quantify relative odds of spread. SETTING: Academic referral center. PATIENTS: Consecutive sample of all referred patients treated by a single Mohs micrographic surgeon in a 3-year period. MAIN OUTCOME MEASURE: Number of Mohs micrographic surgical layers required to clear a tumor, with 3 or more layers defined as extensive subclinical spread. RESULTS: The highest-risk tumors, with odds ratios greater than 6.0, were basosquamous and morpheaform basal cell carcinoma (BCC) on the nose, morpheaform BCC on the cheek, and those with a preoperative size greater than 25 mm. Other important risk factors were recurrent and nodular BCC on the nose; location on the eyelid, temple, or ear helix; neck tumors and recurrent BCC in men; and tumor size greater than 10 mm. Patients younger than 35 years were at lower risk. Increasing age and immunocompromise were not significant predictors. CONCLUSION: Identification of lesions likely to exhibit extensive subclinical spread can help guide management to ensure complete tumor eradication and thereby reduce the risk of recurrence and its associated morbidity and cost.

A risk scale for predicting extensive subclinical spread of nonmelanoma skin cancer.

BACKGROUND: The clinical appearance of nonmelanoma skin cancer may represent only a portion of microscopic tumor invasion. OBJECTIVE: To develop a scale based on high-risk characteristics for predicting the probability of extensive subclinical spread of nonmelanoma skin cancer. METHODS: Retrospective analysis of 1095 Mohs micrographic surgical cases (MMS) yielded high-risk factors for extensive tumor spread, defined as requirement of greater-than-or-equal3 MMS layers. Predictive characteristics included: any BCC on the nose, morpheaform BCC on the cheek, neck tumors and recurrent BCC in men, location on the eyelid, temple, or ear helix, and size>10 mm. Multivariate logistic regression was applied to develop a risk index. RESULTS: Tumor characteristics were assigned point values calculated from the respective odds of extension and categorized into six risk classes with probabilities of extensive subclinical spread ranging from 10% to 56%. CONCLUSION: A risk scale simplifies and enhances prediction of extensive tumors. The associated probabilities can help to guide patient preparation and appropriate therapy.

Immunohistochemical staining of lentigo maligna during Mohs micrographic surgery using MART-1.

BACKGROUND: Lentigo maligna (LM) often displays extensive subclinical spread. Mohs micrographic surgery (MMS) has been proposed to help delineate the true histologic margin; however, visualizing atypical melanocytes on frozen section is challenging and often requires confirmatory permanent paraffin sections. OBJECTIVE: Our aim was to use a monoclonal antibody to rapidly stain frozen sections during MMS to facilitate better visualization of atypical melanocytes. METHODS: Frozen sections of LM during MMS were stained with MART-1 (melanoma antigen recognized by T cells) and compared with paraffin-embedded sections. RESULTS: We found 100% correlation between frozen sections stained with MART-1 and paraffin-embedded sections. CONCLUSIONS: Atypical melanocytes can be better visualized on frozen sections of LM by using MART-1 rather than hematoxylin and eosin. This allows for easier identification during MMS and better chance of complete removal of LM lesions.